10 WHITE ST - BUILDING INSPECTION (22) SJ The Commonwealth of Massachusetts
Board of Building Regulations and Standardsla *kueftwkwo
Town of
Massachusetts State Building Code, 780 CMR, 7'"edition �
Building Dept
Building Permit Application To Construct, Repair, Renovate Or De
�f One- or ruo-Fmnill Duelling
` O This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Budding Commiss o e nspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Pr�eOrty.l ti C /� 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street?yes_ ' no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(ft)
1.5 Building Setbacks(B)
From Yud Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system O
Check if yesCl
SECTION 2: PROPERTY OWNERSHIP'
ptariefDescription
AV
f Record: Q/i
o� / J�
Address for Service:
�YU
TSECTION Ji DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
ion O Existing Building O Owner-Occupied O Repairs(s) 0 Alteration(s) ❑ Addition OO Accessory Bldg. O Number of Units_ Other a Specify:n of Proposed Work': w
a
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S s—.s O
�0 1. Building Permit Fee: S Indicate how fee is determined:
2. ElectriF
S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
J Plumb S 2. Other Fees: $
4. .MechaHVAC) S List:.5 .MechaFire SSu ressi Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) �✓Z /
License Number E puation ate
Nype ut'CSI�, pldeL J /s„ List CSL T
YDe Ix'c below) nV
. - T Description
U Unrestricted(up to 35.000 Cu. Ft.)
R Restricted 1&2 Family Dwcllm
S n rt yy .M Masonry Only
RC Rcsidemial Ron2 Coverin
Telephone ws Resdential Window and Siding
SF Residential Solid Fuel Burning Appliance installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
-Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuanc of the building permit.
Signed Affidavit Attached? Yes.......... No...........❑
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject property hereby
authorize _ to act on my.behalf,in all matters
relativg to work authorized by t is building permit application.
8i nature of O ner Date
SECTION 7b:O!n,;R' Ojt AUTHORIZED AGENT DECLARATION
j as Owner or Authorized Agent hereby declare
that the statements and informati n on the foregoing application are true and accurate, to the best of my knowledge and
beha .
tnt
&fgifawWorowner or Authorized Agent Batt
Si ned under the pains and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will M have access to the arbitration
program or guaranty fund under M.G.L. c. 1.42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.R3. respectively.
FWhen substantial work is planned,provide the information below:
rs area(Sq. Ft.) (including garage, finished basement/attics, decks or porch)
g area(Sq. Ft.) Habitable room count
f firepiaces Number of bedrooms
f bathrooms Number of halfbaths
ating system Number ofdecks/ porches
oling system Enclosed Open
1. "Total Project Square Footage" may he uhslituted for 'Total Project Cost"
i
The Com monivealth of/lfassaclursetts
De urrtnrent o
l flndasfriaLAc'cidents
Office of IIIresrr,,atiorrs
c•�=;_'. 7^t,t 600 Ih'a.rhii,tore Street
Boston, MA 02111
"' rvtvfn.mass.�ot�/rlirr
Workers' Compensation Insurance Affidavit: Buil(lers/Contractors/l�,lectl-icians/13Iu , 1)crs
Applicant Information
)'lease Print Lceibl�
Fame (1]n51rC55t01^_1lIi,ri,,l ndividun p:
Address:
City/State/Zip: _//jG a5 < /Z Phone : _70 — d 9,S/�Nt0
Arc you an employer? Check the appropriate t)Ox:
1, FD
(rcquircd):
®- I am a employer with z� 4. ❑ I am a general contractor and 1employees (full and/or part-time).' pare hired the sub-contactors truction2.❑ I am a sole proprietor'or partner- listed on the attached sheet ngship and have no employees These sub-contractors hare_working forme in any capacity plo�ees and have workers' ncm[No workers' comp. insurance comp. insurance.* addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions j
3.❑ 1 am a homeowner doing all work officers have exercised their 1 LEI Plumbing repairs or additions
myself. [No workers' comp, right of exemption per MGL
insurance required.] t C. 152, §1(4), and we have no 12.❑ Roof repairs
emplovees. [No workers' 13.L,' Other Gf'+-;,I_ 7
comp. insu:z,r'e ;cquired.] I �
— ---
i
':\n)'applicam that checks bo.c q nwst also fit out the section be oTshowing their workers'compensation policy information.
i Homeowners aho submit this affidavit indicating they arc doing all work and Then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
I ant ilij,orlit eu:player that is provid a wo leers'conrpetrsation insurance for my employees. IJelory is the policy and job site
Insurance Company Name:_ w < -
Policy#or Self-ins. Lic. C Z// �/'(o/ p 9 Expiration Date: -O R /D
Job Site Address:1Q S City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date),__
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi ,under the pain/penalties ofperjury that the information proviged abo a is rue and correct.
Si azure, Date \ ��
Phone#:
Official Ilse only. Da not it-rite is this area, to be cootplcted bl,ci!r or tomes official
City or Town: Permit/License #
Issuing Authority(circle one):
1. Board of Health 2. Building Depar(ment 3. Citv/foru'n Clerl: 4. Electrical Inspector 5. Plumbing Inspector
(- Other
I1 Contact Person: _ _ Phone r':
'= �I;t„achu Net is - Dclt;u-Inunt of Pu Ill ic S:Ifch
Board of Buildin, Re-Illations and Standards
Construction Supervisor License
License: CS 60219
Restricted to: 00 .
MARK TRAINA
33 HANFORD RD
STONEHAM, MA 02180
Expiration: 4/27/2011
( nnmis�iuu•r Tr#: 14425
Client#: 635556 PETERPAR2
DATE'CERTIFICATE OF LIABILITY INSURANCE 416/1
rrooucER j CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
US[ Ins Sery of AiA, Inc Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P O Box 920444 DER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Needham, MA 02492
ERS AFFORDING COVERAGE NAIC#
wsuaeD A: Hanover Insurance Company 22292
Peterson Party Center Inc B: Liberty Mutual Insurance Company 23043
139 Svranton StWinchester, MA 01890 c�D'E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR 14SRI TYPE OF INSURANCE POLICY NUMBER POLICY-EFFECTIVE POLICY-EXPIRATION
DATE MMDONY DATE(hlWDDn`YJ LIMITS
A GENERAL LIABILITY ZBN6482025 10/09/09 10/09/10 EACH OCCURRENCE S1 000 0OO
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
REt rc=arE 53C0.000
CLAIMS MADE OCCUR MED EXP IAny one Person) �5 pOO
PERSONAL G ADV INJURY S1 GOO 000
GENERAL AGGREGATE E2 000,000
GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP ADS E2 OOO O00
POLICY X PRO-
JECT X LOC
A AUTOMOBILE LIABILITY AMN6398554 10/09/09 10/09/10
COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $1,000,000
ALL OWNED AUTOS
X SCHEDULED AUTOS BODILY INJURY(Per E
pereon)
X HIRED AUTOS
BODILY INJURY
X NOR OWNEDAUTOS (PeracCdent) $
PROPERTY DAMAGE $
(Per¢cadent)
GARAGE UABILITY AUTO ONLY-EA ACCIDENT $
ANYAUTO
OTHER THAN EA ACC S
- AUTO ONLY: AGO S
A EXCESSNMBRELLALIABIUTY UHN6482021 10/09/09 10/09/10 -- EACH OCCURRENCE $5000000
X OCCUR CLAIMS MADE AGGREGATE ES 00O 000
S
DEDUCTIBLE
E
RETENTION E None _ - - _ E
B WORKERS COMPENSATION AND WC2Z11259617029 10/09/09 10/09/10 X WC STATLL oTH.
EMPLOYERS'LIABILITY - -
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500000
OFFICER/MEMBER EXCLUDED?
It yes,descnBe uMer E.L.DISEASE-EA EMPLOYEE $500 000
SPECIAL PROVISIONS W. E.L.DISEASE-POLICY LIMIT SS00000
OTHER
FIESCRObnN OF OPERATIONS I r OCATICINS I VFHICLPS I FrOI USIONS ADDED BY ENDORSEMENT/SPEC WL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL . In DAYS WRITTEN
- NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALE - -
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORQED REPRESENTATIVE
ACORD 25(2001108) 1 of 2 #S4312552/M4063373 BJECG 0 ACORD CORPORATION 1988
--Jr1j,2 :PPrJPs 1 M TA N T D O C U M ENT EP�P,00c.rL Effl PrJP11 C
h;
ISSUED BY 5
REGISTPA (AN !`fT F Date of Shipment 5
APPLICATiG
itr< d � ? 5/12/2005 5
a �� 5
rill NUMBER �ju� 'n NousTRic iNc
-- Tent Identification Cj
+. 5 r EVANSVILLE, INDIANA 47725 5�Ta
r oao4sm PIaU I y e ° MANUFACTURERS OF THE FINISHED 5
5 TENT PRODUCTS DESCRIBED HEREIN 5
5 This is to certify that the materials described have been flame-retardant treated 5
M (or are inherently noninflammable) and were supplied to: 5
ri 657150
PETERSON PARTY CENTER INC 5
ti139 SWANTON ST 5
2 5
r I� `A!INCHESTER MA 1890
�I 5
5
'SI 5
5
Certification is hereby made that: - 5
15jThe artir_ ;�s described on this Certificate have been treated ,kith a flame-retardant approved c5J
chemical and that the application of said chemical was done in conformance with California 5
L0 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5
L
L' Serial d 801o�00c(2) 5
5
5
� Description of item certified: [5+
FIESTA"I OP 16Ws24 while 511}N I 5
r
Fj Flame Vletardant Process Used Will Not Be Removed By 5
e Washing And Is Effective For The Life Of The Fabric 5
5 SNYQER nlro Neva rt-iIL. DEt.PHIA.oli
J SPECIAL EVENTS DIVISION•ANCHOR INDUSTRIES INC.
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